Plan how you’ll disclose unanticipated outcomes

In addition to writing a policy on the disclosure of unanticipated outcomes, you should have an actual mechanism in place for responding to an incident, says Janice Piazza, RN, MSN, MBA, director of advance learning workshops for VHA East in Berwyn, PA. Don’t wait until the next crisis to determine how you will respond.

Sometimes there is little time to make decisions, she says. The hospital or other organization must be ready to respond even if the doctor is available to make a decision about if, when, and how to disclose, she says.

"When the nurse looks at the chart and says, Oh no!’ on Friday night, the patient is going to ask what’s wrong," Piazza says. "You can’t just say, Let’s wait until Monday when the doctor will be in.’"

You also need to decide how you will respond when not all the necessary information is available. Disclosure can be especially difficult when the outcome is dreadfully unexpected but the cause isn’t completely understood yet. What do you say?

"You can say that you don’t know exactly what happened, but you will inform them as soon as possible," she says. "And you explain how you are looking for an answer."

Disclosure tips

These are some more tips for how to disclose:

Work with the patient’s and the family’s needs, not your own.

When you need to meet with them again, ask when it is convenient for them, Piazza suggests. Don’t say you’ll meet them with them next Tuesday at 10 a.m. because that’s the only time you can get everyone together. Focus on the patient’s and family’s needs rather than expecting them to work around your schedule. Remember that they may need time to process the information you’ve given them, or maybe to get someone else to join them at the next meeting.

Encourage physicians to get some advice before disclosing.

Even when disclosure is necessary, it’s not a good idea for a surgeon to walk out of the OR and say, "We made a mistake." It’s better for the doctor to consult with the risk manager or a peer, partly to get some advice, but also just so there is time to calm down and decompress from the incident.

Stephen Prather, MD, senior vice president for physician leadership with VHA, says any physician, nurse, or other clinician about to disclose an unanticipated outcome should first take the time to talk to a peer. The discussion can alleviate some nervousness and fear, and the peer can help determine the best way to approach the patient or family.

"They can go through scenarios and dialogues for how to disclose," he says. "Physicians will be very open to ideas unless they’re completely denying there’s a problem. The peers should remind them that disclosure is always difficult, even for the most experienced and talented physician."

Develop a support system for clinicians who must disclose.

In addition to developing and publishing a policy, provide resources to clinicians. The materials can include tips on how to best talk with patients and family, with possible dialogues and scenarios.

Avoid trying to intimidate a physician into disclosing.

Sometimes when a physician is reluctant to disclose, the risk manager is tempted to go over his or her head to the department head or director of medicine. Bad idea, says Grena Porto, RN, ARM, DFASHRM, senior director of clinical operations at VHA.

"If you force a reluctant physician to disclose, he’s probably going to do it badly, and that’s not what you want," she says. "It’s more productive to find out why the physician is reluctant and try to counter that. If he’s afraid he’s going to be sued, tell him that’s just true and he could be saving himself some legal trouble by disclosing."

Pay special attention to residents.

Residents can pose two different kinds of problems. Either they are too eager to disclose and do so without proper supervision, or they are too afraid to report an error to their attending. And if the attending physician does not know of the error, he or she can’t put into motion the process for disclosing it.

Remember that disclosure will be stressful for the clinician.

No matter how seasoned the provider, this moment can be extremely stressful and emotional. Patients and family can become angry with the bearer of bad news, no matter how carefully it is delivered. Be prepared to provide some assistance, perhaps by having peers ready to talk to the person afterward.

Don’t commit your insurance company to anything.

Insurance policies usually include a statement that you can’t obligate them to pay for anything. Don’t let that discourage you from disclosing, but be careful what you say.

You can say, "We amputated the wrong leg." But you can’t say, "We amputated the wrong leg, but our insurance will take care of it."

Don’t be afraid to apologize.

Apologies are good, Porto says, and they’re becoming more common. Human beings respond strongly to someone saying that he or she is sorry, so it can diffuse a lot of anger. California, Texas, Massachusetts, Vermont, and Georgia have laws or case law that prohibits an apology being introduced as evidence. Even in other states, courts are unlikely to see a simple apology as an admission of guilt.

"But sincerity is crucial," Porto says. "Don’t think you can make some administrator the apologist’ and have him or her going around apologizing for everything."